Headlines about "Health plan costs - managed care"

Gathered from the web by the editors at BenefitsLink.com.
GAO Study Describes Cost-Sharing Requirements and Dollar Limits Under Federal Health Plan for Expensive 'Speciality' Drugs
11 pages. Excerpt: "Specialty prescription drugs are typically used to treat chronic or life-threatening conditions, such as multiple sclerosis and cancer, for which few other treatment options exist. . . . Costs for specialty prescription drugs are usually high, typically ranging from $1,200 to $40,000 for a 30-day supply. . . . To manage the high and rising costs of these drugs, some health plans have begun to require enrollees to contribute a greater share of their costs, such as by increasing the use of coinsurance. You asked us to examine the costs that FEHBP enrollees may incur for specialty prescription drugs." (U.S . Government Accountability Office)

Number of HMOs as of July 2008
Source: Healthleaders, Inc., Special Data Request, March 2009. (Kaiser Family Foundation)

Waste-Reduction Strategies Can Improve Health Care Quality With Reduced Costs
Excerpt: "In 'Imagining 16% to 12%: A vision for cost efficiency, improving health care quality, and covering the uninsured,' [Milliman sets] forth 'actuarial insights to help health care reformers develop better proposals' while reducing health care's share of the gross domestic product (GDP) from the current 16% to 12%. The Milliman team's strategies support those of the Obama Administration to reduce costly waste in health care by relying more on evidence-based medicine, using comparative effectiveness evaluations of new and existing treatments to identify those that are the most cost effective, setting quality standards and measures, making providers accountable for outcomes, encouraging informed patient choice, and promoting electronic medical records, among other steps." (Wolters Kluwer)

Impact of Two Employer-Sponsored Population Health Management Programs on Medical Care Cost and Utilization (PDF)
8 pages. Excerpt: "Conclusions: Our results suggest that the programs did not reduce medical cost in their first year, despite a beneficial effect on hospital admissions. If we had been able to include program fees, it is likely that the overall cost would have increased significantly. Although this study had important limitations, the results suggest that a belief that these programs will save money may be too optimistic and better evaluation is needed." (The American Journal of Managed Care)

Report on California Health Plans and Insurers
Excerpt: "Private health insurance carriers form the backbone of California's market-based health care system, providing coverage to 67% of its population. Health insurance carriers not only serve the privately insured, but also large portions of the publicly insured, in Medi-Cal, Healthy Families, Medicare, and other public programs. [Both the report and data files are linked from the target page.]" (California HealthCare Foundation)

[Guidance Overview] Hospital Not Entitled to Notification That Participant Was in COBRA Election Period
Excerpt: "Although apparently not raised by the hospital, the IRS COBRA regulations require an indemnity or reimbursement plan to make a complete response to any inquiry from a health care provider regarding a qualified beneficiary's right to coverage under a plan during the COBRA election period. However, this provision of the regulations refers only to indemnity and reimbursement plans -- HMOs (such as the one in this case) and other plans providing services (such as walk-in clinics) are not mentioned. Nevertheless, such plans may decide to adopt the disclosure practices in the IRS regulations for provider inquiries during the COBRA election period as a way to avoid disputes and potential liability (including possible state-law misrepresentation claims), even though these disclosures technically may not be required." (Employee Benefits Institute of America)

[Opinion] Alain Enthoven Responds on Reform of the Dutch System
Excerpt: "[In the JHPPL article by Pauline Vaillancourt Rosenau and Christiaan J. Lako, 'An Experiment with Regulated Competition and Individual Mandates for Universal Health Care: The New Dutch Health Insurance System' t]he authors referred to the Dutch reform as 'Enthoven-inspired.' Alain C. Enthoven, [known as the 'father of managed competition,' provides this response:] Don't leap to unfounded conclusions too quickly in this complex and important subject." (Physicians for a National Health Program)

Insurers Hire Radiology 'Benefits Managers' to Vet Scanning
Excerpt: "Health insurers are increasingly relying on outside firms to help rein in the skyrocketing costs of imaging scans like MRIs. But when these middlemen clash with doctors about what tests are needed, consumers can get caught in the crossfire. Big insurers including Aetna Inc., WellPoint Inc. and Cigna Corp. have hired so-called radiology benefits managers, or RBMs. Health plans say they want to ensure that doctors use high-tech scans only when it is clear that patients will benefit." (The Wall Street Journal)

The Changing Effect of Managed Care on Physician Financial Incentives
Excerpt: "Objective: To examine how managed care affects physician financial incentives to reduce services to their patients, particularly how this relationship has evolved over time and whether the effects of capitated managed care and noncapitated managed care are different. . . . Conclusion: Managed care and traditional indemnity plans were substantially more similar in their effects on physician incentives to provide care by 2004-2005 than they were just 3 years earlier. This should alleviate policy concerns that managed care is providing physicians with the 'wrong' financial incentives to provide care." (The American Journal of Managed Care)

Healthier Consumers, Customers and Communities: The Hannaford Dynamic (PDF)
4 pages. Excerpt: "This issue of our 2008 Perspectives series looks at how Hannaford Supermarkets used a 'quality paradigm' -- focusing on quality care, efficiency, evidence-based medicine and cost control to dramatically lower its health care spend while lifting employee satisfaction and perception of quality." (Towers Perrin)

Fight Back When Your Health Plan Says No
Excerpt: "Bernadine Healy, MD, former director of NIH and now health editor at US News & World Report, has written a chilling piece on how easy it is for insurers to deny claims. From the article, 'How Crafty Health Insurers Are Denying Care' . . . ." (Health Insurance Consumer Information)

Patients Suffer As Care, Coverage Limits Collide; Physicians Say Insurers Intrude on Treatment
Excerpt: "Increasing healthcare costs and an influx of expensive drugs and tests, combined with an aging population, set off a healthcare crisis in the United States. Contending with soaring costs, insurers changed the business of health care by requiring preauthorizations, mandating cheaper drugs, and tightening controls on treatment decisions. But among the first casualties of these changes, many physicians said, was the doctor-patient relationship." (Toledo Blade)

Insurers Using Radiology Benefit Managers To Cut Down on Unnecessary, Costly Imaging Procedures
Excerpt: "Health insurers are increasingly denying coverage for medical imaging procedures recommended by physicians that are judged to be unnecessary, in an attempt to reduce health care spending by $30 billion annually, according to a report released on Monday by America's Health Insurance Plans, Bloomberg/Hartford Courant reports." (Kaiser Family Foundation)

[Opinion] Health Insurance Companies and the Managed Care Roller Coaster
Excerpt: "'Managed care' is, to many, a nasty phrase. But the truth is that the insurer who understands that 'managing care' means making sure that customers get the high-quality care they need, when they need it, will save money. When it comes to health care, low cost and high quality go hand-in-hand. At the same time, 'managing care' means avoiding ineffective care." (The Century Foundation)

Mercer's HRadio Podcast, July 15, 2008
This week's lineup includes: News highlights; Understanding health care predictive models; Hurdles in the road to global pay; Socially responsible investing goes mainstream. Total time: 15:26 (Mercer LLC)

Graphs Show HMO Rate Increases by Region (PDF)
2 pages. Excerpt: "As U.S. companies begin to negotiate HMO plan rates for 2009, data from Hewitt Health Resource™ (HHR) -- a Web site that captures HMO rate information for 160 large companies representing approximately 1 million participants -- shows that initial 2009 HMO rate increases are averaging 11.8 percent, compared with estimates of 13.2 percent in 2008 and 11.7 percent in 2007." (Hewitt Associates)

2009 HMO Cost Hikes Down from 2008
Excerpt: "The good news for employers is that the rate of cost increases for health maintenance organizations (HMOs) is predicted to slow for 2009, but it is still out in front of inflation. That was the word from Hewitt Associates which gathered HMO rate data from its Hewitt Health Resource site, which features data from 160 large companies with about 1 million participants." (PLANSPONSOR.com; free registration required)

Quality Monitoring and Management in Commercial Health Plans (PDF)
Excerpt: "This survey of 252 HMOs found that almost all measure their performance on multiple indicators of quality and most use these data in quality improvement activities." (The American Journal of Managed Care)

[Guidance Overview] Futility Doctrine Applied in Aid of Class Action Claims Against HMO Defendants
Excerpt: "In this recent decision, the plaintiffs alleged that the defendant HMO's routinely overcharged for services. The defendants met these claims with a motion to dismiss for lack of subject matter jurisdiction and failure to exhaust administrative remedies. The plaintiffs prevailed on most issues in an decision that sheds light on Article III standing requirements and application of the futility doctrine." (Health Plan Law blog by Attorney Roy F. Harmon III)

[Opinion] Healthcare Reform -- Nobody's Asking the Hardest Question: Who Gets Care and When
Excerpt: "I believe that without a mechanism to control what care is available and to whom and at what time, costs will continue to be a problem. We have more technology than we can afford. In national health care systems care is rationed by either long waits or guidelines that restrict access." (Jeffrey Clayton on the BNA Pension & Benefits Blog)

High Healthcare Costs Caused in Part by Power of Healthcare Systems, Wisconsin Study Says
Excerpt: "High health care costs in the Milwaukee area stem from the market power of health care systems, according to a study by the Wisconsin Policy Research Institute. The study contends that health care systems have increased their market power by employing physicians, which gives them a referral base for their hospitals, which makes it harder for would-be competitors to enter the market." (Milwaukee Journal Sentinel)

Summary of the Colorado Managed Care Review 2007
Excerpt: "This is the 14th edition of Allan Baumgarten's annual analysis of trends and issues in the Colorado health care market. Baumgarten, an independent analyst and researcher on health finance in local markets has published his Colorado market study since 1994 He also publishes annual market reports in California, Florida, Illinois, Kentucky, Michigan, Minnesota, Ohio, Texas and Wisconsin. A new Arizona study will be published in 2008." (Allan Baumgarten)

[Guidance Overview] HMO Loses Third Party Beneficiary Contract Dispute With Health Care Providers
Excerpt: "In this health care provider versus HMO dispute, the providers chalked up a win. Having successfully moved for remand following the HMO's attempt to convert the payment controversy into an ERISA action, the HMO asserted ERISA preemption as an affirmative defense. The trial court, and subsequently, the appellate court, found this defense unavailing." (Health Plan Law blog by Attorney Roy F. Harmon III)

Shepherding Major Health System Reforms: A Conversation With German Health Minister Ulla Schmidt (PDF)
10 pages. Excerpt: "During her tenure with the German health ministry, Ulla Schmidt has overseen major system reforms, balancing social solidarity with fiscal responsibility." (Health Affairs)

A Living Model of Managed Competition: A Conversation With Dutch Health Minister Ab Klink (PDF)
8 pages. Excerpt: "The Dutch government's centrist approach to health reform with an individual insurance mandate could provide another model for U.S. reform efforts." (Health Affairs)

'Medical Home' Concept Embraced by IBM and Other Employers
Excerpt: "[T]he hallmarks of a 'medical home' are an ongoing relationship with a doctor; a team approach to delivering comprehensive, coordinated care that is integrated across the health care system; the use of tools, such as electronic medical records, to ensure that care is delivered safely and prevents redundancy and medical errors; and expanded access, including evening and weekend office hours and the use of e-mail and telephone consultations . . . ." (Financial Week; free registration required)

[Opinion] Bars to Managed Care Lawsuits - A Historic Review
Excerpt: "Historically, managed care companies have been afforded immunity from negligence and malpractice lawsuits. Several state and federal bars, including ERISA (Employee Retirement Income Security Act of 1974), have insulated managed care companies from liability relating to the treatment of patients. Likewise, managed care companies have historically been immune from malpractice committed by a health care member of its panel of providers." (The Executive Post @ Healthcare Financials.com)

Proposal Could Lift Fee Limits Imposed on HMOs by State of California
Excerpt: "The way that state regulators levy penalties and fees on HMOs is coming under intense scrutiny in the Capitol. And now one Democratic senator is trying to remove what is effectively a limit on fines against health providers." (Foundation for Taxpayer and Consumer Rights)

Health Insurance & Managed Care Compilation of Statistics and Articles Updated March 3
Excerpt: "For most Americans, market-based health insurance remains the predominant form of health coverage." (National Conference of State Legislatures)

Adviser Sheds Light on PBM Conflicts of Interest
Excerpt: "Fiduciaries could be breaching their responsibilities under ERISA if the revenue streams going to PBMs are not fully understood by the sponsor. Which begs the question: do your clients know about all the money you're making from their PBM relationship?" (Employee Benefit Adviser)

Adviser Sheds Light on PBM Conflicts of Interest
Excerpt: "Fiduciaries could be breaching their responsibilities under ERISA if the revenue streams going to PBMs are not fully understood by the sponsor. Which begs the question: do your clients know about all the money you're making from their PBM relationship?" (Employee Benefit Adviser)

Conversations on The Changing Face Of Managed Care: Insights from Managed Care Magazine's Podcast Series (PDF)
34 pages. Articles include 'Seeing Through Transparency [from the Employer's Perspective],' 'Electronic Health Information,' 'The Future of Disease Management' and 'Consumer-Directed Health Plans." (Managed Care)

Wal-Mart Signals Its Move Into the PBM Industry; Analysts Have Mixed Reactions
Excerpt: "Wal-Mart Stores, Inc.'s plan to start offering pharmacy benefit services to employers has provoked mixed reactions from PBM industry stakeholders. While some observers contend that any move by the retail behemoth has the potential to be an industry 'game changer,' two of the largest PBMs appeared unfazed by the prospect of a giant new competitor." (AISHealth.com)

Healthcare Data Pooling: Coming Soon to a Community Near You?
Excerpt: "Everyone can agree that quality healthcare is a good thing. But how do we go about measuring quality? Intrepid organizations in Massachusetts, Minnesota, Washington, and Wisconsin are answering the call for measurable quality metrics by developing data-pooling operations that can report on healthcare quality." (Milliman)

California Regulators Faulted for Altering State Law on HMO Guidelines
Excerpt: "Physician groups and patient advocates are criticizing the Department of Managed Health Care for failing to comply with a state law that seeks to improve timely access to care for HMO members, the Los Angeles Times reports." (California HealthCare Foundation; free registration may be required)

Total Health Management Strategies and Success Factors (PDF)
4 pages. Excerpt: "This issue focuses on THM success factors for sponsors of multiemployer health plans and includes a case study. The value of THM is not merely theoretical. Plan sponsors that have implemented a THM strategy have already seen savings." (The Segal Group, Inc.)

CMS Outlines Value-Based Healthcare Purchasing Program
Excerpt: "CMS this week outlined its long-awaited value-based purchasing program (VBP) proposal that would reduce diagnostic-related group (DRG) payments for Medicare patients, but give hospitals a chance to earn the money back through stellar performance or dramatic improvement. . . . Karen Linscott, acting CEO of The Leapfrog Group, said in a statement. 'Now that CMS' plan for value-based purchasing has been made public, the public and private sector can leverage their combined purchasing power to cure the toxic payment system by implementing payment policies that are based on higher quality rather than volume.'" (HealthLeaders Media)

More Health Insurers Adopt Doctor Ranking Model
Excerpt: "More health insurers have adopted New York Attorney General Andrew Cuomo's doctor ranking model, thereby agreeing to fully disclose to consumers, physicians and plan sponsors the cost and quality metrics they use to rank doctors." (Workforce Management)

Seven Ways to Lower Benefit Costs Without Decreasing Coverage
Excerpt: "Fear not, my HR brothers and sisters. Here are my Cliff notes for the top seven strategies to drop benefit costs without decreasing coverage. There's still time to get these in for 2008." (Workforce Management)

UK Fat Patients Claim Discrimination
Excerpt: "In Britain, some doctors appear to be setting a body mass index of 30 -- considered obese in Britain and the United States -- as an informal cutoff point for elective surgery. In the U.S. there are no absolute limits, but American doctors seem to be more lenient. One U.S. orthopedic surgeon suggested that not until a patient has a body mass index of 40 -- a category considered 'morbidly obese' -- would surgeons have serious problems." (AP via Yahoo! News)

Conversations on the Changing Face of Managed Care: Insights from the 2006–2007 Podcast Series (PDF)
34 pages. Excerpt: "Managed care executives are inundated almost daily with information, which they need to read and process to keep up with the rapid changes taking place in health care. This supplement is based on a series of 10 podcasts that were conducted in late 2006 and the first half of 2007 to give health care professionals an opportunity to learn about new developments in managed care. The host for the series was Ian Morrison,PhD, an internationally known author, consultant, and futurist specializing in long-term forecasting and planning. Each podcast consisted of a discussion between Morrison and an expert on an issue important to the business and bottom line of managed care organizations." (Managed Care Magazine)

Health Care Vendor Summits Promote Integration of Services (PDF)
6 pages. Excerpt: "Plan sponsors that must deal with a plethora of health care management and wellness vendors are pushing for greater coordination and integration among vendors. This trend stems from the fact that employee populations today have a variety of health and wellness issues that require different levels of interventions, such as case management to direct the delivery of care, and disease management for those who have chronic illnesses, as well as health coaching, wellness and prevention." (International Foundation of Employee Benefit Plans)

Managed Care Contract Gives Rise to 'Independent Legal Duty' Which Survives ERISA Preemption
Excerpt: "[T]he United States District Court in Northeast Hosp. Authority v. Aetna Health Inc. ultimately added another decision to growing list of cases in which managed care contracts permit payment disputes between provider and health plan to survive ERISA preeemption. The contours of a successful argument for provider reimbursement are taken from the outline of critical factors set forth in AETNA Health, Inc. V. Davila 542 U.S. 200 (2004)." (Health Plan Law blog by Attorney Roy F. Harmon III)

Self-Insured Employers Must Hold Service Providers' Feet to the Fire
Excerpt: "When employers self-insure, they usually look to hundreds of available external administrative firms to manage claims and managed-care services. However, there is little oversight on these companies from public regulators or private compliance specialists. Thus, the most effective tool for vendor management is a two-fold approach that requires performance guarantees up front and ongoing oversight through periodic claim audits to evaluate and confirm reported accuracy results." (Employee Benefit News; free registration required)

Study Shows Active Company Health Plan Managers Enjoy Lower Cost Increase
Excerpt: "A press release about Towers Perrin's annual Health Care Cost Survey says 'high-performing companies' will see annual per-employee costs of about $1,500 less than low performers in 2008. While nearly a quarter of the survey respondents continue to struggle with double-digit cost increases, nearly half of the high performers are managing to get their increases much closer to the medical CPI of about 4%. Among high performers, 45% have cost increases of 5% or less." (PLANSPONSOR.com; free registration required)

New Products that Combine an HRA with an HMO Are Gaining Traction in California
Excerpt: "Since being launched in June, a product that pairs an HMO with a health reimbursement arrangement (HRA) has been gaining sales traction in California, according to Health Net of California, Inc. The managed care company's Optimizer HMO is among a growing number of products that combine the features of an HMO or point-of-service (POS) plan with a health account." (Inside Consumer-Directed Care via AISHealth.com)

Pharmacist-Coordinated Health Management Delivers ROI (PDF)
Pages 1-2 of pages. Excerpt: "While the health care costs for employees with chronic conditions will continue to be higher than average per employee costs, these pharmacist-coordinated programs are helpingto narrow the gap." (Pharmacy Benefit Management Institute, LP)

Companies Adopt Financial Incentives for Doctors
Excerpt: "Beginning in 2008, IBM, Wachovia, Novant-Presbyterian Healthcare, Belk and Duke Energy will reward physicians who provide quality care based on national standards. The five Charlotte, N.C. area companies have partnered with the Charlotte Health Care Collaborative in an effort to improve quality care for their workers." (Employee Benefit News; free registration required)

Managing Health Care Cost and Quality Through Predictive Data Analytics (PDF)
3 pages. Excerpt: "Read about how the emerging power of predictive analytics, coupled with advances in technology, can provide the tools and insight needed to effectively manage health care plans for the long term." (Aon Consulting)

2007 SHPS Health Practices Study: What Every Self-Insured Employer Should Know (PDF)
28 pages. Excerpt: "The 2007 SHPS Health Practices Study substantiates that traditional financially based cost management methods are simply not enough to battle rising healthcare costs. Companies with the lowest healthcare costs focus on optimizing employee health and managing clinical risk, rather than manipulating the health benefit." (SHPS)

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